The Importance for Massage Therapists of Understanding Medical Conditions

When I commenced my journey into massage therapy back in 1997, it all seemed very straight forward, the biggest thing to remember was the list of contraindications.

But as massage therapists we treat clients with a whole array of medical conditions, which means we need not only to recognise contraindications, but be competent in working around them to offer our clients a safe service. However, very few massage therapists are fortunate enough to have the medical and surgical background required for this and so they are often uncomfortable and lacking competence in terms of assessing a client for contraindications. The reason for this is that there is a very large hole in current entry level training regarding how to deal with medical conditions safely and effectively. Massage students can come away with an example of a contraindication form but if they don’t know how to use it or how to act on the answers, what good is it?I am a firm believer that every massage therapist, like nurses, midwives and other healthcare professionals, must work within their competency level and be accountable for their own practice. So if a therapist recognises that there is an issue with how to manage medical conditions, it is their responsibility, as part of continuing professional development, to pursue further training and access research to better serve the clients who are coming to them. Just so you are aware, my background has involved teaching surgical skills to student nurses, running active birth workshops as a midwife and teaching Swedish massage to couples and parents.

Most entry level massage training courses are very good at teaching practical elements and basic anatomy and physiology, but not so much, I think, in the realities of the reasons why massage may be being sought by their clients. I have seen therapists, in the six months I worked alongside them, put the health of two clients seriously at risk simply because their understanding of physiology was still at a basic level and their knowledge of medical conditions was lacking. Particularly for people who will go on to train others, it is crucial, as a teacher, that their knowledge base upgrades appropriately and beyond what might have been being taught a few decades ago.

While the basic information being taught has not changed in 23 years, client demographics and clients’ reasons for having a massage treatment have changed dramatically. More and more clients seek to combine complementary and conventional healthcare. What used to be a luxurious pampering treatment is often now a complementary medical treatment for chronic medical conditions. Perhaps this stems from the discovery that massage treatments can relieve pain in terminally ill patients, something which used to be seen as a contraindication. The massage profession is now proving its effectiveness through conventional research methodology, leading the scientific community to acknowledge we complement to the medical profession.

This is something that excites many massage therapists I know, but in order to walk through that door, it is essential that in today’s society massage therapists have a good understanding of common medical conditions, the systems of the body that are affected, the underlying causes, signs and symptoms, side effects of medications, and indications/contraindications for massage in order to devise safe treatment plans for their clients. It is also necessary that they are confident in treating clients with medical issues, aware of the risks and know when to refuse treatment or refer to another professional, to ensure the best outcome for the client. Client health and safety have to be prioritised over filling diaries.

A second issue is that many therapists are not registered with a regulatory body. For clients this means that there is no support in the case of a complaint where they believe their health may have been put at risk through lack of knowledge. Clients may expect therapists to be able to explain how their medical condition is impacting on muscle tension, while therapists may not have the knowledge of experience to be able to do this. For therapists, this also removes the possibility of exoneration by a recognised body in the case of a false complaint.

By familiarising ourselves with causes and treatments, as well as just symptoms, we can assess a client’s tolerance level and adjust techniques, positioning and maybe the length or type of treatment. The issue is that the majority of therapists with basic training would not know to ask for this information, and often clients don’t mention such things because they’re living with the condition every day, so it becomes their normal. Knowing that your client takes warfarin, for example, is helpful only if you know what to look for and what questions to ask. As an example, a lady contacted me to book in a massage. When she filled out the medical questionnaire, it became apparent that she had antiphospholipid syndrome and osteoporosis (which had resulted in a broken pelvis in 3 of the 4 years prior). Clients like her who are on warfarin (an anticoagulant) should be regularly attending a warfarin clinic to be monitored and the therapist must ascertain whether such a client is controlled. If she is not then treatment is contraindicated, as it could potentially cause a bleed which could lead to a stroke. With this particular client, her antiphospholipid syndrome meant that she was prone to blood clots, which was also a concern, and would affect the massage techniques used and potentially the areas to be treated. As with many on warfarin, this client was prone to excessive bruising, and her legs were dark purple all over, so even a Swedish massage would not be suitable. If, however, the client was controlled and the skin was not discoloured, and if she didn’t have osteoporosis, which was clearly a major problem for her, then some form of treatment may have been given with liaison with her GP prior to treatment. Had this client been treated with, for example, a deep tissue massage, this could have resulted in a broken bone, a blood clot or bleed which could cause a stroke, or more extensive bruising.

Asking about medication can offer equally valuable information, even if you are unfamiliar with the medication, as it can offer information about a condition not previously mentioned by the client, or about side effects that may present themselves during the treatment. My general advice is that therapists obtain a BNF (British National Formulary), if they do not yet have one, which will allow them to look up medications and inform themselves of possible side effects and uses.

On the whole my observations are that self-employed therapists are often better at the consultation because they often allow more time and are not restricted by company policies and time limits. Therapists who work in busier settings, however, or within companies can often gain insight into a client’s medical history by asking simply whether a client is under the regular care of a doctor and if so why. Not only might this highlight something that isn’t on the contraindication list, but it may explain the issue for which the client booked a treatment, and allow you to coordinate treatment around visits to another professional, for example, an osteopath. It may also indicate something that is a factor in how you carry out the treatment, and if the client is undergoing tests without a definitive diagnosis at the time of treatment, any suspected diagnosis should be taken into account. For example repeated stomach aches may be due to stress, for which massage will benefit, or it may be due to an undiagnosed ulcer.

For example, if a client comes in for lower back pain, but upon asking you then discover that they take doxazosin, a blood pressure medication, this may lead to further questions. Is the medication controlling their blood pressure? Has the client experienced any side effects? Doxazosin, can cause vertigo and dizziness, so the client may need to sit up slowly after treatment. Also high blood pressure is traditionally on the old contraindication list due to improved circulation being an effect of massage, but research has shown that massage is beneficial to hypertensives because of the effect on the nervous system, causing vasodilation of blood vessels which reduces the intra-arterial pressure. However, the therapist also needs to check for a history of stroke/heart disease because if these are present then the hypertension becomes a true contraindication, due to the increased risk of causing one of these issues, and putting the client at risk. Another question to be asked is if there are any signs of atherosclerosis or peripheral artery disease, which will affect the type of massage given, the techniques used, and possibly the area treated. So what may initially seem like a straightforward case of backache, becomes a much more complex scenario, hence why every therapist must continue to develop their knowledge, if only to educate themselves about the kind of questions they should be asking to safeguard their clients.

I think we all understand that each client is an individual and needs treatment that is individualised, but this can only truly happen if we have the knowledge, experience, and clinical and ethical judgement required to fully understand a client’s medical history. I have found that my clients really appreciate that I can offer something different due to my medical experience, and that I have a higher level of understanding about their condition. Even in my work as a sports therapist, it’s amazing how much of my midwifery knowledge I use. That’s why I decided to start teaching courses, to empower therapists with a focus on risk factors, causes, treatments etc so that they can ask the right questions and offer an appropriate treatment.

January 2021